Acute Kidney Injury and Acute Coronary Syndromes

Marenzi G, Cosentino N, Bartorelli AL.
Acute Kidney Injury in Patients With Acute Coronary Syndromes. Heart 2015;101:1778-1785.

The following are 10 points to remember from a review on acute kidney injury in patients with acute coronary syndromes (ACS):

  1. The clinical manifestations of acute kidney injury (AKI) range from minimal increase in serum creatinine (sCr) to anuric renal failure requiring renal replacement therapy.
  2. AKI in ACS is a multifactorial phenomenon that involves interplay among the following features: underlying renal dysfunction, negative impact of iodinated contrast, impaired cardiac output with arterial underfilling, and increased venous congestion with venous overfilling.
  3. The reported incidence of ACS-associated AKI is highly variable, ranging from 5% to 55%.
  4. sCr concentration is an unreliable measure of kidney dysfunction in the acute setting. When glomerular filtration rate acutely decreases, sCr rises slowly (usually within days) and may not change until about 50% of kidney function has decreased.
  5. AKI impacts short-term prognosis in those with ACS. In particular, a significant progressive increase in in-hospital mortality was observed in patients with ACS between those without AKI and those with stage 1, stage 2, and stage 3 AKI (1% vs. 9.5% vs. 43%).
  6. One-year mortality in patients with acute myocardial infarction is also impacted by the severity of AKI.
  7. Even a transient increase in sCr >0.5 mg/dl in patients with ACS is independently associated with a twofold increase in 6-month mortality.
  8. Renal blood flow and clearance function may remain impaired for a prolonged period of time after AKI, even though sCr may normalize.
  9. About 40% of patients developing AKI during ACS had evidence of persistent deterioration of AKI (>25% or >0.5 mg/dl increase in sCr above baseline), and this was a strong independent predictor of 5-year mortality.
  10. The authors point out, “The majority of patients with AKI are not being routinely followed by nephrologists, and follow-up for mild AKI barely exists in the current clinical practice.” The authors opine that “filling this gap may represent a major opportunity for a significant improvement in the care of this population.”

Clinical Topics: Acute Coronary Syndromes, Vascular Medicine

Keywords: Acute Coronary Syndrome, Acute Kidney Injury, Anuria, Creatinine, Hospital Mortality, Hyperemia, Kidney Function Tests, Myocardial Infarction, Renal Circulation, Renal Replacement Therapy

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